January 17, 2008 This report details the Task Force's findings and recommendations from January through May 2007. It does not include the actions taken since May 2007 to correct the identified gaps or implement these recommendations. For information about actions already completed and underway, please see the following information paper. BG Donald Bradshaw Chairman Traumatic Brain Injury Task Force 1
Information Paper DASG-HSZ 17 January 2008 SUBJECT: Traumatic Brain Injury (TBI) Task Force Report Recommendation Summary 1. Purpose: To provide information of the progress of TBI Task Force recommendations. 2. Definition. a. Implemented - Work with Inter-Agency (DoD/DVA) and Civilian groups on the definition and further the taxonomy of TBI. b. In Progress - Develop a single academically rigorous, operationally sound definition for the case ascertainment of TBI (especially mild TBI) to facilitate accurate screening, evaluation, diagnosis, treatment, and education. 3. Screening. a. Implemented - Implement in theater TBI screening and documentation for all soldiers exposed to Blast. b. Implemented - Add TBI specific screening questions to the PHA, PDHA and the PDHRA to assess for TBI. c. In Progress - Develop an Army wide post-deployment TBI screening tool and implement/conduct post-deployment TBI screening at every de-mobilization site for all Soldiers. d. In Progress - Develop an appropriate tool and conduct TBI screening for all patients who are evacuated from theater who are appropriate for screening. e. In Progress - Develop and implement TBI screening policy at all echelons of care. The policy will encompass all mechanisms of TBI occurring both within and outside the theater of operations. f. In Progress - Conduct screening with a consistent team trained to perform this function. 4. Baseline Neuropsychological Evaluation. a. In Progress - Implement a baseline (pre-deployment), post deployment and post-injury/exposure neuropsychological evaluation using the Automated Neuropsychological Assessment Metrics (ANAM). 2
b. In Progress - Utilize ANAM for neuropsychological testing per Acute In Theater Care Clinical Practice Guidelines (CPG). 5. Outreach Program. a. In Progress - Propose outreach programs through the Deputy Chief of staff for Personnel (DCSPER) for soldiers separated from the Army since 2003 to facilitate identification of mild TBI and to initiate treatment if needed - possibly similar to Gulf War Registry. 6. Traumatic Brain Injury Center of Excellence. a. Implemented - Develop a proposal on the appropriate functions of a TBI Center of Excellence (COE) for MEDCOM to submit to HA. b. Implemented - Propose the DVBIC as the core of a the new COE for DoD and DVA. c. Implemented - Optimize the positioning of clinical, educational and research activities. d. In Progress - Utilize the Defense and Veterans Brain Injury (DVBIC) model of a joint/interagency network for TBI. e. In Progress - Evaluate the impact of expansion of DVBIC sites to all MTFS. f. In Progress - Establish and utilize a proponency office to address TBI health integration and rehabilitation that serves as the main proponent for all TBI inquiries, issues, policy development and implementation for OTSG/MEDCOM and executes recommendations of the TBI Task Force through a process that includes timelines, tracking and interagency coordination of actions. 6. Treatment. a. In Progress - Develop a system-wide policy to institute identified best practices across the continuum of care for patients with all degrees of TBI. This system-wide effort should include development and implementation of in-theater concurrent screening protocol; acute in-theater management of mild TBI CPG; standardized early symptomatic treatment after identification; identification of a POC for TBI issues and deployment of a Neurologist with every CSH. b. In Progress - Establish deployment/redeployment TBI programs including: primary care, social work, case management, and behavioral health programs based upon the Fort Carson model at each installation. Population needs may reveal the need for an enhanced or reduced version of the Fort Carson model. In 3
some cases a regionally based MEDCOM TBI Surge teams may meet the needs of sites with few and infrequent re-deployments. c. In Progress - Develop and implement a policy to establish critical positions for TBI care at every MTF based upon added mission and available resources. At a minimum there will be two critical positions that will be essential: A TBI POC (the go-to person for all issues related to TBI at that facility) and a TBI specific care coordinator or clinical case manager. d. In Progress - The DVA facilities should be the first option of care for inpatient and outpatient rehabilitation for Soldiers requiring care beyond the capability of the MTF. Exceptions to use of the DVA should be reviewed by the MTF Deputy Commander for Clinical Services (DCCS) with second level review by the nearest regional MTF DCCS to facilitate consistent, fair and equitable decision making across the AMEDD. e. In Planning - Coordinate with DVA (VHA/VBA) to establish a utilization review of benefits. 7. Case Management. a. In Progress - Implement a population based model for CM support which is reflective of best practices across the DoD and DVA. Establish a standardized definition of military CM for the Army and start CM processes as early as possible from the point of injury across the continuum of care. b. In Progress - Establish a standardized documentation template for TBI CM Army-wide according to the level of care. Provide accessible documentation systems needed to enhance communication in each care venue with a smooth transition to the next site or level of care. 8. Research. a. Implemented - Centralize evaluation of the scientific merit, clinical utility, and priority of new treatment strategies, devices or interventions (basic, clinical, applied research efforts). Clinical research will be synchronized with basic science and technology. All TBI research will be coordinated, integrated and vetted through USAMRMC. b. In Progress - Conduct centralized, standardized reporting to determine the actual incidence and prevalence of TBI, with focus on mild TBI. The current disparate methods of identifying TBI at the point of occurrence or at other times in the care process suggest that any effort to gather this data without standardization will yield very questionable and easily challenged findings. 4
c. In Planning - Develop a mechanism for collecting the frequency, severity, care and outcomes of TBI to provide adequate, reliable data for analysis to assist in care and decision-making. d. In Planning - Coordinate, synchronize, and conduct multi-center clinical research on TBI under a centralized authority. 9. Family Issues. a. In Progress - Provide psychosocial supports for Soldier, family members and staff, to include: support groups (GWOT and TBI sensitive); individual and family counseling utilizing models of care adapted to the needs of family members of a brain injured individual. b. In Progress - Recommend placement of military liaisons at the VA Polytrauma Network Sites. c. Refer to another Agency - Review benefits packages provided by TRICARE, DVA and Medical Assistance (MA) (e.g. non-governmental organizations, advocacy groups, and volunteers) to determine optimal uniform package. d. Refer to another Agency - Establish new uniform benefit sets that include both the entitlements and healthcare benefits to serve those with minimal needs as well as those with lifelong needs. Examples of areas that need to be addressed include: therapies required to meet the individualized treatment plan; housing, including supported living, home modifications, and long term care; healthcare, to include in-home and outpatient care as needed based on individual care plan; medical equipment; temporary transitional living; support for daily living to include independent living services, homemaking services, meals on wheels, and behavioral treatment plans; community participation, to include educational support services, vocational rehabilitation, structured day programs, sports and leisure activities, and social activities. e. Refer to another Agency - Provide resources for family members who have chosen to leave their jobs to care for a service member. Consider provision of health insurance for family members who provide full-time care to an injured service member/veteran. f. Refer to another Agency - Recommend placement of USAR chaplains at each of the four DVA Polytrauma Rehabilitation Centers for additional psychosocial support services. 10. Education. 5
a. In Progress - Develop and disseminate standardized education products that provides a practical overview of TBI to Soldiers, family members and unit commanders to increase their TBI proficiency and improve the positive, accurate identification of symptoms. This product will include general TBI information, other pre-deployment issues which may include living wills and powers of attorney, and a standardized explanation of all levels of care. Provide ongoing periodic refresher sessions to improve the retention of information. b. In Progress - Educate and train providers on TBI specific screening tools, proper evaluation, appropriate treatment, documentation requirements (mechanism of injury/nature of injury, Glasgow Coma Scale (GCS), level of consciousness (LOC), Post Traumatic Amnesia (PTA)), models for grief and loss counseling and care giver support. Provide continuing medical education credit. c. In Progress - Provide TBI education to medical providers at MEPS stations, everyone involved in the Physical Disability Evaluation System, and coders. d. In Progress - Provide consistent, in-depth education throughout the continuum of care for family members, Soldiers and care professionals, to include the following: clinical condition (TBI); benefits and entitlements; and simplified understanding of the DoD PDES. e. In Planning - Encourage and reinforce unit leaders to capture data about potential concussive events as a part of mission recovery and after action review. Correlate this information with Soldier, medic, combat lifesaver and buddy reporting. Identify Soldiers in need of observation as they may have had a TBI and require a short periodic stand down for full recovery. 11. Marketing. a. In Progress - Continually market TBI successes via command groups, Public Affairs Offices and as many media outlets as possible. Potential topics include DVA Polytrauma System of Care liaisons; DVA care educational videos; DVBIC consultation and educational offerings, outstanding examples of MTF care, personal accounts from Soldiers and their Families, and the positive care experiences received by noncombatants. b. In Progress - Produce commercials briefly outlining the processes, improvement initiatives and preponderance of positive outcomes to provide a more balanced account. c. In Progress - Keep Soldiers and their Families informed by actively marketing the methodology, status and outcomes of studies conducted within and external to DoD/DVA. 6
12. Documentation. a. Implemented - Adapt the Military Acute Concussion Evaluation (MACE) overprint as an approved DA Form to document mild TBI closest to the point of injury. b. In Progress - Develop and use an Electronic Medical Record (EMR) that follows a Soldier from the point-of-injury to the Veterans Affairs Healthcare System. When multiple electronic systems are in use, ensure data interface between systems. c. In Progress - Standardize documentation for TBI to include capture of all data elements necessary for accurate classification of the injury, standard use of AHLTA templates, and uniform documentation of caregiver assistance (for TSGLI). d. In Progress - Establish and formalize the procedure for all Army MTFs to report TBI data (utilizing a standardized definition and identification methodology) to DVBIC. Joint coordination required for Soldiers in non-army MTFs. 13. Physical Disability Evaluation System. a. In Progress - Participate in a review of the PDES by the DA and DoD being conducted by specific process action teams. Monitor process improvement recommendations in the following categories: automation, counseling/training, medical evaluation board/physical evaluation board process, and transition. Evaluate and update AR 40-501, Standards of Medical Fitness to include specific guidance on TBI. 7